Childhood Asthma

Asthma is one of the most common chronic diseases affecting children. Millions of American children have asthma, which impacts their daily lives in many ways. Parents often are unclear what asthma is and how it can be managed; however, asthma can be controlled and children with asthma can lead normal lives. If your child has asthma, learn all you can about this disease and take time to stay up to date on the latest treatments.

This fact sheet provides detailed information about asthma in children. We hope that this material helps you better understand the nature of asthma, how to recognize symptoms, and how to manage asthma on an ongoing basis. Please keep in mind that this information is not meant to take the place of medical advice from your own physician.

Eight-year-old Jon has had asthma since he was an infant. He is able to recognize the onset of his asthma symptoms and knows a lot about how and when to take his medications.

His neighbor, 14-year-old Eliza, gets exercise-induced asthma when she runs track. She uses medicine to control escalating asthma symptoms.

Eliza’s cousin, seven-year-old Sasha was adopted from Kazakhstan. His new parents soon found that Sasha’s aversion to dairy products was well founded—tests showed he had an allergy to cow’s milk, causing his ongoing wheezing and coughing. When they eliminated products made with cow’s milk, his asthma symptoms went away.

Sasha’s karate classmate, 10-year-old Myron missed a lot of school during the fall and winter of fifth grade because of his asthma—his parents have no health insurance and his medical care is spotty. The school nurse noticed his pattern of sickness and absence and referred his mother to a local free clinic, where the care he received greatly improved his health.

What is asthma?

Asthma is a disease characterized by chronic inflammation of the airways. This inflammation causes narrowing of the airways and an increased sensitivity to inhaled irritants and allergens. Allergens and irritants are substances found in our everyday environment. People with asthma are said to have hyperactive airways, meaning their respiratory tract overreacts to things that would just be minor irritants for people without asthma.

The root cause of asthma is still unknown. However, physicians do know that an increase in asthma symptoms often results after having a respiratory infection or when the sensitive person comes into contact with various allergens, engages in vigorous exercise, inhales cold air, or is exposed to air pollution. Common symptoms of asthma include wheezing, coughing, shortness-of-breath, and a feeling of chest tightness.

Asthma can begin at any age. With proper management and education, people with asthma can lead normal, active lives.

Fast facts about asthma and children . . .

• Asthma is one of the most common chronic childhood illnesses.

• Nine million U.S. children under 18 have been diagnosed with asthma.

• Asthma is a leading cause of school absences.

• In a classroom of 30 children, two or more children are likely to have asthma. (In some states or local areas the rate is much higher.)

• From 1980-1994, the rate of asthma in children under the age of five increased more than 150%.

• In the year 2000, 4.6 million children under age 18 were seen in physicians’ offices and hospital clinics for asthma treatment, and more than 728,000 children under age 18 had asthma-related visits to the emergency department. That same year, at lest 214,000 children under 18 were hospitalized due to asthma.

Which children are most likely to develop asthma?

Certain risk factors make some children more likely to develop asthma.

Heredity. To some extent, asthma seems to run in families. Children whose brothers, sisters, or parents have asthma are more likely to develop the illness themselves. If both parents have asthma, the risk is greater than if only one parent has it. For some reason, the risk appears to be greater if the mother has asthma than if the father does.

Atopy. A child is said to have atopy (or to be atopic) when he or she is prone to developing allergies. Being atopic causes the body to respond to allergens by producing an antibody known as immunoglobulin E (IgE) antibodies. Substances in the environment that cause an allergic reaction—such as pollen, mold, or animal dander—are known as allergens. When the body of an atopic child is stimulated by an allergen, IgE molecules are made that recognize and bind to the allergen. Once IgE molecules are made, they bind to the surface of cells capable of releasing the chemicals that cause allergic reactions. At this point, the child is sensitized to the allergen. Encountering the allergen again leads to binding of the allergen to IgE molecules on the cell surface and this interaction triggers the cells to release the chemicals that cause an allergic reaction.

Certain types of allergies can increase a child’s risk of developing asthma.

When the allergic reaction takes place in the airways, they become inflamed and constricted. Children inherit atopy from their biological parents. However, it is not the same as inheriting a specific type of allergy. Rather, being atopic means only having a tendency to develop allergies. In other words, both the child and the parent might be allergic to something, but not necessarily the same thing.

Are allergies and asthma related conditions?

Yes. For many people, including children, an allergic response can trigger various symptoms of asthma; however, allergens are not the only trigger of asthma symptoms.

What can trigger asthma in children?

It’s important to be aware of the things in your child’s environment that tend to make asthma flare. The ways in which children react to asthma triggers vary. Some children experience symptoms only in response to a combination of triggers. For others, exposure to a single trigger may be the cause of escalating asthma symptoms.

Some of the more common factors, or triggers, are described here.

Allergens. Some allergens (substances that cause an allergic response in sensitive individuals) are more likely to trigger an asthma episode. For instance, very young children may have food allergies that result in asthma symptoms. Some of the foods to which American children are commonly allergic are eggs, cow’s milk, wheat, soybean products, tree nuts, and peanuts.

In toddlers, common allergens that trigger asthma include house dust mites, molds, and animal dander. For older children, pollen may be a likely allergen, but indoor allergens and molds are more likely to be a cause of asthma symptoms.

Viral infections. Some types of viruses can trigger asthma. Two of the most likely viruses affecting children are the respiratory syncytial virus (RSV) and parainfluenza virus. RSV can cause diseases of the bronchial system known as bronchopneumonia and bronchiolitis. A young child who has wheezing with bronchiolitis is likely to develop asthma later in life. Parainfluenza affects the respiratory tract in children, sometimes causing bronchitis (inflammation of the bronchi) or pneumonia (inflammation of the lining inside the lungs).

Tobacco smoke. Many people are unaware that smoking is a significant risk factor for asthma in children and a common trigger of asthma symptoms for people of all ages.

Of course, people with asthma should never smoke tobacco products, but they also should take care to avoid the smoke from others who are smoking. This “secondhand” smoke, or “passive smoking,” can trigger symptoms in people who have asthma. Studies have shown a clear link between secondhand smoke and asthma in young people. Passive smoking worsens asthma in children and teens, and it causes thousands of new cases of asthma each year.

Airborne irritants. In addition to secondhand tobacco smoke, other irritants in the environment also can trigger asthma symptoms or acute asthma episodes. These irritants include smog; aerosol sprays of all kinds; fumes from paint; cleaning products or chemicals in the home, school, or workplace; and even perfumes and other fragrances.

Exercise. Vigorous physical activity—especially in cold air—is a frequent asthma trigger. In fact, there is a type of asthma called exercise-induced asthma (EIA). Symptoms of EIA may not appear until after several minutes of sustained exercise. The kind of physical activity that can bring on asthma symptoms also includes things like laughing, crying, holding one’s breath, and hyperventilating (rapid, shallow breathing). Symptoms of EIA usually go away within a few hours.

With proper treatment, a child with EIA does not need to limit overall physical activity.

Each case of asthma is unique. It is important for parents to keep track of the factors or triggers that seem to provoke a child’s asthma. Because symptoms do not always occur during or immediately after exposure, this effort may take a bit of detective work. Once you know those triggers, you can take steps to manage your child’s exposure to them.

What are the symptoms of asthma in children?

Common symptoms of asthma include the following physical changes.

Wheezing is a high-pitched, whistling sound that your child may make when the airways become inflamed or tighten in response to an asthma trigger. If you hear this sound when your child breathes, be sure to let your physician know. Not all people who wheeze have asthma, and not everyone who has asthma will wheeze. In fact, if asthma has become severe, there may not be enough air movement through the child’s airways to produce a wheezing sound.

Chronic cough, especially at night and after exercise or exposure to cold air, can be a symptom of asthma.

Shortness of breath, or difficulty breathing, or feeling of not being able to get enough air is another possible sign of asthma. All children get out of breath when they run and jump, but most resume normal breathing very quickly afterward. If your child doesn’t, a visit to your physician is a good idea.

Tightness in the chest is a symptom that you may have to ask your child to describe for you. If you notice any of the other signs of asthma, it’s a good idea to ask your child whether there is a tight, uncomfortable feeling in the chest.

How is asthma diagnosed in children?

Asthma is sometimes hard to diagnose because it can resemble other respiratory illnesses or conditions. For that reason, asthma is under-diagnosed and therefore, under- treated. Sometimes the only symptom is a chronic cough at night, or cough and wheezing after exercise.

To diagnose asthma and distinguish it from other lung disorders, your child’s pediatrician will rely on a combination of things: the child’s medical history, a thorough physical exam, and laboratory tests. These tests may include spirometry (measuring lung function with specialized equipment); peak flow monitoring; chest X-rays; and possibly blood and allergy skin tests. To help your physician make the best diagnosis possible, bring a record of your child’s symptoms and experiences with asthma symptoms when you have an appointment.

What is the treatment for asthma in children?

Treatment needs to be tailored for each child. One general rule that does apply, though, is to remove those things from the child’s environment that you know act as triggers for asthma symptoms. Reducing household dust mites, mold, animal dander, and cockroach debris can be helpful—especially in the child’s bedroom. When these measures are not enough, it may be time to try one of the many medications that are available to control asthma symptoms.

Guidelines from the National Institutes of Health (NIH) advise treating asthma with a “stepwise” approach. This means using the lowest dose of medication that is effective, and then “stepping up” the dose and the frequency with which it is taken if the asthma symptoms get worse. When the asthma gets under control, the medicines are then “stepped down.”

The goals of asthma treatment for children are:

• Restful, nighttime sleep

• Avoiding the need for hospital stay or emergency treatment

• Ability to engage in normal play and activities

• Normal lifestyle, with no restrictions due to asthma

What medications are commonly used for treating asthma in children?

Asthma medications fall into two main categories:

Quick-relief medications

Long-term control medications

Quick-relief medications provide immediate relief of asthma symptoms by relaxing the muscles around the airways and making breathing easier. These medications begin to work within minutes after they are used, and their effects may last for up to six hours. Most quick-relief medications are used with an inhaler. They can be taken before exercise to help prevent or reduce asthma symptoms.

Long-term control medications work over time to reduce the frequency and severity of asthma symptoms and acute asthma episodes. Unlike the quick-relief medications, long-term control medicines do not provide quick relief of asthma symptoms. Most of these medications take at least a week or more of regular use to achieve their full effect. This type of medicine only works when taken consistently.

Long-term control medications can be classified into four broad categories. These are described briefly below.

Corticosteroids. Steroids are the most potent and consistently effective long-term control medications available. Corticosteroid medications can be taken orally in pill or liquid form, or inhaled, using a MDI. Children with moderate to severe persistent asthma may take an inhaled form of this drug on a regular basis. Oral steroids may be prescribed for more serious symptoms. Side effects of inhaled steroids are relatively minor, especially when compared with the long- term benefit of using them. Oral steroids can have systemic (total body) side effects if taken for long periods of time. Discuss these side effects in relationship to your child with the pediatrician.

Inhaled mast cell stabilizers. These are taken using a metered dose inhaler (MDI), which delivers a measured amount of medication each time it is used. Many of these medicines also can be taken using a nebulizer.

Long-acting bronchodilators. These medications act to relax the muscles around the airways when they tighten in response to an asthma trigger. When the airways relax, air then can pass through them better making breathing easier again. Effects of long-acting bronchodilators last up to 12 hours, and like the inhaled anti-inflammatory medicines, they continue to work only if they are taken regularly. Side effects from these kinds of medications are minor. Long-acting bronchodilators are usually used in combination with inhaled corticosteroids. Their use alone is generally not recommended.

Leukotriene modifiers. These medications — fairly new to asthma treatment — prevent and reduce airway inflammation and constriction. They also make airways less sensitive to asthma triggers and can reduce the need for short-acting reliever medications. Leukotriene modifiers seem to have fewer side effects than other asthma medications, although some patients do experience some minor side effects. They are not as effective as inhaled corticosteroids.

Sometimes asthma medications are combined to provide better treatment than any one used alone can offer.

Is it easy to give asthma medicine to children?

Asthma medications are available for use in a variety of forms, making it fairly easy to administer them to children of all ages. Most asthma medications are available in several forms. Talk with your child’s pediatrician or your pharmacist about options for taking asthma medications.

• Liquids. Often useful for young children. These medicines also can be flavored.

• Pills. Vary in size. Older children and teens may be able to use this form.

• Inhaler. A portable device which patients use to inhale their medication in one or two breaths per dose.

• Nebulizer, a small machine that creates a “medication mist”—patients inhale over the course of about 10-15 minutes. Especially useful in treating young children.

• Injection, normally not used unless for emergencies (epinephrine in an Epi-Pen®) or very serious or out of control asthma requiring hospitalization, with medications given intravenously (IV).

Who should treat children who have asthma?

Many children are treated for asthma by their pediatrician; however, if your child’s asthma symptoms are not under control within three to six months, or if symptoms are severe and persistent, or if asthma episodes require emergency treatment, it may be time to see an asthma specialist. Allergists/Immunologists or pulmonologists (who specialize in the treatment of lung diseases) are specialists who treat asthma. Those who have completed training in those specialties are usually called board-certified or board- eligible.

Does health insurance cover asthma treatment?

Most health insurance plans provide some level of coverage for asthma patients. Check with your insurance carrier for details. Some things you may want to find out might include:

• Do you need a referral to an asthma care specialist from your child’s pediatrician?

• Does the insurance carrier offer any patient education or specialized services related to children and asthma?

• What medications are not covered by your plan? (There can sometimes be a delay in approving newly released medications. Your physician may know about them, but your insurance may not cover them yet.)

The information provided in this fact sheet should not be a substitute for seeking responsible, professional medical care.

Reprinted with permission from “Asthma and Allergy Answers,” the patient education library developed by the Asthma and Allergy Foundation of America.